Chronic mesenteric ischemia: Diagnosis and management

Optimizing Outcomes for Acute Mesenteric Ischemia in the Context of Hypogammaglobulinemia: A Detailed Analysis of Surgical and Medical Strategies

Acute mesenteric ischemia is a critical condition marked by a sudden loss of blood supply to the intestines, often leading to rapid tissue necrosis and severe clinical outcomes if untreated. In the context of hypogammaglobulinemia, an immunodeficiency characterized by decreased levels of immunoglobulins, this vascular emergency becomes even more daunting. Hypogammaglobulinemia can impair the immune system's response to both infection and ischemic injury, intensifying the severity of intestinal damage. This report describes the case of a 52-year-old female with hypogammaglobulinemia who presented with severe abdominal pain. Surgical exploration revealed 100 cm of necrotic small bowel extending from 150 cm distal to the ligament of Treitz to within 10 cm of the ileocecal valve. The necrotic section was surgically removed, and primary anastomosis was performed. This instance highlights the significant impact of immunodeficiency on the progression and management of acute mesenteric ischemia, demonstrating the critical need for early intervention and tailored management strategies, especially in immunocompromised patients, to prevent severe outcomes. The case illuminates the importance of recognizing immunodeficiency as a complicating factor in acute gastrointestinal emergencies, stressing the necessity for prompt and effective medical and surgical interventions to improve prognosis and patient outcomes in complex clinical scenarios.

Therapeutic effect and study of human umbilical cord blood mononuclear cells in patients with ischaemic bowel disease

Ischaemic bowel disease (ICBD) is a group of intestinal ischaemia syndromes caused by various aetiologies of reduced intestinal blood flow or vascular occlusion. ICBD can present as abdominal pain, bloody stool, and diarrhoea. This disease often occurs in middle-aged and elderly individuals with cardiovascular and cerebrovascular diseases. The incidence of ischaemic bowel disease has been increasing for decades, and it is difficult to diagnose, resulting in rapid disease progression and a high mortality rate. Therefore, fully understanding this disease, improving the diagnosis rate of this disease, and finding appropriate treatment methods are urgently needed to improve the condition and prognosis of patients. Umbilical cord blood stem cells are accessible, have weak immunogenicity, and have various biological functions, such as angiogenesis, inflammation and immune regulation. Many studies have confirmed that cord blood stem cells can relieve ischaemia, and these cells have attracted tremendous amounts of attention in regenerative medicine in recent years. In this paper, we discuss the clinical characteristics of ICBD, analyse the characteristics of human umbilical cord blood mononuclear cells (HUCB-MNCs), and use its to treat ischaemic bowel disease. Additionally, we compare the clinical manifestations and related indicators before and after treatment to evaluate the efficacy and safety of these methods.

Intestinal Ischemia - Etiology and Foundational Concepts

Intestinal Ischemia: Etiology and Foundational ConceptsThe authors provide an overview of the intestinal anatomy and the pathophysiology and etiology of intestinal ischemia.

Extent of Abdominal Aortic Calcification Is Associated With Incident Rapid Weight Loss Over 5 Years: The Perth Longitudinal Study of Ageing Women

BACKGROUND

Abdominal aortic calcification (AAC), a marker of vascular disease, is associated with disease in other vascular beds including gastrointestinal arteries. We investigated whether AAC is related to rapid weight loss over 5 years and whether rapid weight loss is associated with 9.5-year all-cause mortality in community-dwelling older women.

METHODS

Lateral spine images from dual-energy x-ray absorptiometry (1998/1999) were used to assess AAC (24-point AAC scoring method) in 929 older women. Over 5 years, body weight was assessed at 12-month intervals. Rapid weight loss was defined as >5% decrease in body weight within any 12-month interval. Multivariable-adjusted logistic regression was used to assess AAC and rapid weight loss and Cox regression to assess the relationship between rapid weight loss and 9.5-year all-cause mortality.

RESULTS

Mean±SD age of women was 75.0±2.6 years. During the initial 5 years, 366 (39%) women presented with rapid weight loss. Compared with women with low AAC (24-point AAC score 0-1), those with moderate (24-point AAC score 2-5: odds ratio, 1.36 [95% CI, 1.00-1.85]) and extensive (24-point AAC score 6+: odds ratio, 1.59 [95% CI, 1.10-2.31]) AAC had higher odds for presenting with rapid weight loss. Results remained similar after further adjustment for dietary factors (alcohol, protein, fat, and carbohydrates), diet quality, blood pressure, and cholesterol measures. The estimates were similar in subgroups of women who met protein intake (n=599) and physical activity (n=735) recommendations (extensive AAC: odds ratios, 1.81 [95% CI, 1.12-2.92] and 1.58 [95% CI, 1.02-2.44], respectively). Rapid weight loss was associated with all-cause mortality over the next 9.5 years (hazard ratio, 1.49 [95% CI, 1.17-1.89]; P=0.001).

CONCLUSIONS

AAC extent was associated with greater risk for rapid weight loss over 5 years in older women, a risk for all-cause mortality. Since the association was unchanged after taking nutritional intakes into account, these data support the possibility that vascular disease may play a role in the maintenance of body weight.

Superior Mesenteric Artery Stenosis Presenting as Chest Pain: Danger in Disguise

Chronic mesenteric ischemia (CMI), often known as abdominal angina, is a syndrome caused by a severe reduction in arterial flow to the digestive loops. It is an uncommon and underdiagnosed entity with potential severe adversities, such as acute mesenteric ischemia (AMI). Patients with coronary artery disease (CAD) are shown to also have mesenteric artery stenosis (MAS). By identifying risk variables, it may be possible to screen for mesenteric artery involvement in patients with CAD who exhibit an elevated risk. Here, we present a unique case of a person with severe retrosternal chest pain with postprandial angina, which turned out to be superior mesenteric artery (SMA) ostial stenosis.

A Systematic Review of Endovascular Repair Outcomes in Atherosclerotic Chronic Mesenteric Ischaemia

OBJECTIVE

Chronic mesenteric ischaemia (CMI) treatment focuses on symptom relief and prevention of disease progression. Endovascular repair represents the main treatment modality, while data on the associated antiplatelet regimen are scarce. The aim of this meta-analysis was to assess the early and midterm outcomes of endovascular repair in patients with CMI.

DATA SOURCES

Randomised controlled trials and observational studies (1990 - 2022) reporting on early and midterm endovascular repair outcomes in patients with atherosclerotic CMI.

REVIEW METHODS

The PRISMA guidelines and PICO model were followed. The protocol was registered to PROSPERO (CRD42023401685). Medline, Embase (via Ovid), and Cochrane databases were searched (end date 21 February 2023). The Newcastle-Ottawa Scale was used for risk of bias assessment, and GRADE for evidence quality assessment. Primary outcomes were technical success, 30 day mortality, and symptom relief, assessed using prevalence meta-analysis. The role of dual antiplatelet therapy (DAPT) was investigated using meta-regression analysis.

RESULTS

Sixteen retrospective studies (1 224 patients; mean age 69.8 ± 10.6 years; 60.3% female) reporting on 1 368 target vessels (57.8% superior mesenteric arteries) were included. Technical success was 95.0% (95% CI 93 - 97%, p = .28, I2 19%, low certainty), the 30 day mortality rate was 2.0% (95% CI 2 - 4%, p = .93, I2 36%, low certainty), and immediate symptom relief was 87.0% (95% CI 80 - 92%, p < .010, I2 85%, very low certainty). At mean follow up of 28 months, the mortality rate was 15.0% (95% CI 9 - 25%, p = .010, I2 86%, very low certainty), symptom recurrence 25.0% (95% CI 21 - 31%, p < .010, I2 68%, very low certainty) and re-intervention rate 26.0% (95% CI 17 - 37%, p < .010, I2 92%, very low certainty). Single antiplatelet therapy (SAPT) and DAPT performed similarly in the investigated outcomes.

CONCLUSION

Endovascular repair for CMI appears to be safe as first line treatment, with a low peri-operative mortality rate and acceptable immediate symptom relief. During midterm follow up, symptom recurrence and need for re-intervention are not uncommon. SAPT appears to be equal to DAPT in post-operative outcomes.

Management of patients with chronic mesenteric ischemia across three consecutive eras

BACKGROUND

Endovascular intervention (EI) is the most commonly used modality for chronic mesenteric ischemia (CMI). Since the inception of this technique, numerous publications have reported the associated clinical outcomes. However, no publication has reported the comparative outcomes over a period of time in which both the stent platform and adjunctive medical therapy have evolved. This study aims to assess the impact of the concomitant evolution of both the endovascular approach and optimal guideline-directed medical therapy (GDMT) on CMI outcomes over three consecutive time eras.

METHODS

A retrospective review at a quaternary center from January 2003 to August 2020 was performed to identify patients who underwent EIs for CMI. The patients were divided into three groups based on the date of intervention: early (2003-2009), mid (2010-2014), and late (2015-2020). At least one angioplasty/stent was performed for the superior mesenteric artery (SMA) and/or celiac artery. The patients' short- and mid-term outcomes were compared between the groups. Univariable and multivariable Cox proportional hazard models were also conducted to evaluate the clinical predictors for primary patency loss in SMA only subgroup.

RESULTS

A total of 278 patients were included (early, 74; mid, 95; late, 109). The overall mean age was 71 years, and 70% were females. High technical success (early, 98.6%; mid, 100%; late, 100%; P = .27) and immediate resolution of symptoms (early, 86.3%; mid, 93.7%; late, 90.8%; P = .27) were noted over the three eras. In both the celiac artery and SMA cohorts, the use of bare metal stents (BMS) declined over time (early, 99.0%; mid, 90.3%; late, 65.5%; P < .001) with a proportionate increase in covered stents (CS) (early, 0.99%; mid, 9.7%; late, 28.9%; P < .001). The use of postoperative antiplatelet and statins has increased over time (early, 89.2%; mid, 97.9%; late, 99.1%; P = .003) and (early, 47%; mid, 68%; late, 81%; P = .001), respectively. In the SMA stent-only cohort, no significant differences were noted in primary patency rates between BMS and CS (hazard ratio, 0.95; 95% confidence interval, 0.26-2.87; P = .94). High-intensity preoperative statins were associated with fewer primary patency loss events compared to none/low- or moderate-intensity statins (hazard ratio, 0.30; 95% confidence interval, 0.11-0.72; P = .014).

CONCLUSIONS

Consistent outcomes were observed for CMI EIs across three consecutive eras. In the SMA stent-only cohort, no statistically significant difference in early primary patency was noted for CS and BMS, making the use of CS at additional cost controversial and possibly not cost effective. Notably, the preoperative high-intensity statins were associated with improved SMA primary patency. These findings demonstrate the importance of guideline-directed medical therapy as an essential adjunct to EI in the treatment of CMI.

Unique multidisciplinary approach in a patient with small bowel obstruction and chronic mesenteric ischemia

Management of small bowel obstruction (SBO) in patients with symptomatic chronic mesenteric ischemia is a phenomenon that has not been previously described in the literature. This is an index case report describing the utilization of a multidisciplinary approach in a patient that suffered from SBO from cecal perforation with history of chronic mesenteric ischemia attributed to superior mesenteric artery (SMA) and celiac trunk stenosis. The patient was a 70-year-old female with recent diagnosis of ischemic colitis and chronic mesenteric ischemia, found to have high-grade SBO with transition point in the right lower quadrant. Computerized tomography angiogram showed occluded SMA, and severe celiac artery stenosis. Interventional radiology revascularized the celiac trunk with stent placement prior to right hemicolectomy for management of her high-grade SBO. Prospective research should ascertain whether revascularization indeed leads to improved post-operative outcomes.

The Global Burden of Vascular Intestinal Disorders in 204 Countries and Territories From 1990 to 2019: Global Burden of Diseases Study

Objectives: Assess the prevalence, mortality, and disability-adjusted life years (DALYs) of vascular intestinal disorders (VID) from 1990 to 2019. Methods: This study conducted a secondary data analysis utilizing the Global Burden of Diseases Study 2019. The prevalence, mortality and DALYs of VID were analyzed by sex, age and socio-demographic index (SDI), respectively. Analyses were performed by using R software. Results: Globally, the number of prevalent VID cases increased from 100,158 (95% uncertainty interval: 89,428-114,013) in 1,990-175,740 (157,941-198,969) in 2019. However, the age-standardized rates (ASR) of VID prevalence declined from 2.47 (95% uncertainty interval: 2.24-2.76) per 100,000 population to 2.21 (1.98-2.48) per 100,000 population between 1990 and 2019. Furthermore, the ASR of mortality also decreased from 1990 to 2019. Between 1990 and 2019, the regions with high and high-middle level exhibited the highest diseases burden. Conclusion: Globally, the diseases burden associated with VID demonstrated a decline from 1990 to 2019. However, concerted efforts are still required to enhance measures to combat VID within countries categorized as high and high-middle SDI.

The pig is a better model than the rabbit or rat for studying the pathophysiology of human mesenteric arteries

AIMS

Animal models are essential to investigate cardiovascular pathophysiology and pharmacology, but phylogenetic diversity makes it necessary to identify the model with vasculature most similar to that of humans.

METHODS AND RESULTS

In this study, we compared the mesenteric arteries of humans, pigs, rabbits and rats in terms of the i) evolutionary changes in the amino acid sequences of α₁ and β2 adrenoceptors; M₁, M₂, and M₃ muscarinic receptors; and bradykinin (BKR) and thromboxane-prostanoid (TP) receptors, through bioinformatics tools; ii) expression of α₁, β₂, M1, M3 and TP receptors in each tunica, as assessed by immunofluorescence; and iii) reactivity to receptor-dependent and independent contractile agonists and relaxants, by performing organ bath assays. Phylogenetically, pigs showed the highest degree of evolutionary closeness to humans for all receptors, and with the exception of BKR, rabbits presented the greatest evolutionary difference compared to humans, pigs and rats. The expression of the measured receptors in the three vascular tunica in pigs was most similar to that in humans. Using a one-way ANOVA to determine the differences in vascular reactivity, we found that the reactivity of pigs was the most similar to that of humans in terms of sensitivity (pD2) and maximum effect of vascular reactivity (Emax) to KCl, phenylephrine, isoproterenol and carbachol.

CONCLUSIONS

The pig is a better vascular model than the rabbit or rat to extrapolate results to human mesenteric arteries. Comparative vascular studies have implications for understanding the evolutionary history of different species.

TRANSLATIONAL PERSPECTIVE

The presented findings are useful for identifying an animal model with a vasculature that is similar to that of humans. This information is important to extrapolate, with greater precision, the findings in arterial pathophysiology or pharmacology from animal models to the healthy or diseased human being.

Collateral circulation develops in stenosis of the celiac trunk and superior mesenteric artery

PURPOSE

Mesenteric circulation is provided by the celiac trunk (CT), superior mesenteric artery (SMA), and inferior mesenteric artery (IMA). The collateral circulation between CT and SMA and between SMA and IMA plays a protective role against intestinal ischemia in case of narrowing or occlusion of the mesenteric vessels. In our study, it is aimed to determine the CT and SMA stenosis rates in patients with CT and SMA stenosis from angiography images, the occurrence of the collateral variations, and the frequency of these variations.

METHODS

A total of 408 non-selective or selective CT and SMA angiographic images were taken of 215 patients (130 males, 85 females) who were admitted to Akdeniz University Hospital with symptoms of chronic mesenteric ischemia (CMI) were included. The angiography images were analyzed in regards to CT and SMA stenosis rates, and the collateral variations between mesenteric vessels.

RESULTS

Stenosis of CT was observed in 14 patients, whereas the stenosis of the SMA was observed in 12 patients. The most common collateral vessel in these patients was the gastroduodenal artery. Both stenoses of CT and SMA were found in 9 patients. The Riolan arch was the most common type of collateral vessel in these patients.

CONCLUSION

It was observed that mesenteric circulation was mainly provided by gastroduodenal artery in patients with isolated CT or SMA stenosis or occlusion while in patients with stenosis or occlusion of both CT and SMA, mesenteric circulation was mainly provided by the Riolan arch. A significant increase was observed in the prominence of collateral vessels in patients with stenosis of more than 70%.

Imaging of Bowel Ischemia: An Update, From the AJR Special Series on Emergency Radiology

Acute mesenteric ischemia is a life-threatening condition that results from abrupt reduction in or cessation of blood flow to the bowel. Characterized by nonspecific abdominal symptoms, mesenteric ischemia is infrequently encountered and commonly misdiagnosed, with potentially catastrophic consequences. Prompt clinical diagnosis and early implementation of therapeutic interventions are critical to improving patient outcomes. Because cross-sectional imaging plays a key role in the diagnosis of mesenteric ischemia, radiologists must be familiar with the varied imaging manifestations of intestinal ischemia. Thus, the objectives of this article are to review the various types and common causes of mesenteric ischemia and to describe its spectrum of multimodality imaging findings, with special attention to novel imaging techniques and emerging diagnoses.

Chronic Mesenteric Ischemia in a Patient With Limited Systemic Sclerosis

Chronic mesenteric ischemia typically develops secondary to the development of atherosclerosis within mesenteric vessels leading to the insufficient blood supply. While autoimmune conditions are an established independent risk factor for developing atherosclerotic plaques, the association between scleroderma and chronic mesenteric ischemia has been less studied. We present a case of a 64-year-old female with limited systemic sclerosis and atherosclerotic cardiovascular disease who presented to the Gastroenterology Clinic with progressive abdominal pain who was subsequently diagnosed with chronic mesenteric ischemia secondary to superior mesenteric artery stenosis and successfully treated with endovascular stenting.

Acute-On-Chronic Mesenteric Ischemia: The Use of Fluorescence Guidance to Diagnose a Nonsurvivable Injury

Mesenteric ischemia (MI) is a condition characterized by compromised intestinal perfusion, leading to varied patterns of bowel hypoxia that requires prompt diagnosis and surgical intervention. Here, we report a case in which indocyanine green (ICG) was utilized to evaluate intestinal blood flow in a patient with acute-on-chronic MI. A 65-year-old underweight female presented with abdominal pain out of proportion to exam and was found to have diffuse aortic atherosclerotic disease with chronic occlusion of both superior and inferior mesenteric arteries with distal reconstitution. After multidisciplinary evaluation, elective treatment with vascular surgery was planned; however, on day three of her hospitalization, the patient’s abdominal pain acutely worsened. She was taken to the OR for exploratory laparotomy. Under white light, the small bowel from the ligament of Treitz (LOT) to the terminal ileum and the large bowel from the cecum to the splenic flexure appeared ischemic with patchy areas of necrosis. Fluorescence angiography was then performed; injection of indocyanine green (ICG) dye and imaging with the SPY-PHI near-infrared camera system demonstrated appropriate blood flow into the bowel mesentery, with complete absence of flow into the bowel mucosal surface from the LOT to the splenic flexure, confirming irreversible bowel necrosis. Introduction of ICG intraoperatively decreased the uncertainty associated with white light assessment of bowel viability, leading to a definitive intraoperative diagnosis and clear plan of care. The use of fluorescence guidance to diagnose fulminant small and large bowel necrosis prevented the surgical team from having to perform multiple takebacks to the operating room in the setting of a nonsurvivable injury. Had the surgical team relied on the white light appearance of the bowel, they would not have been able to diagnose the true extent of bowel demise. The patient was placed on comfort care for this devastating nonsurvivable injury.